Management of infectious complications of intraventricular reservoirs in cancer patients: low incidence and successful treatment without reservoir removal

Leptomeningeal disease in melanoma patients: An update to treatment, challenges, and future directions

In February 2018, the Melanoma Research Foundation and the Moffitt Cancer Center hosted the Second Summit on Melanoma Central Nervous System Metastases in Tampa, Florida. The meeting included investigators from multiple academic centers and disciplines. A consensus summary of the progress and challenges in melanoma parenchymal brain metastases was published (Eroglu et al., Pigment Cell & Melanoma Research, 2019, 32, 458). Here, we will describe the current state of basic, translational, clinical research, and therapeutic management, for melanoma patients with leptomeningeal disease. We also outline key challenges and barriers to be overcome to make progress in this deadly disease.

Leptomeningeal metastasis

Leptomeningeal metastasis (LM) results from dissemination of cancer cells to both the leptomeninges (pia and arachnoid) and cerebrospinal fluid (CSF) compartment. Breast cancer, lung cancer, and melanoma are the most common solid tumors that cause LM. Recent approval of more active anticancer therapies has resulted in improvement in survival that is partly responsible for an increased incidence of LM. Neurologic deficits, once manifest, are mostly irreversible, and often have a significant impact on patient quality of life. LM-directed therapy is based on symptom palliation, circumscribed use of neurosurgery, limited field radiotherapy, intra-CSF and systemic therapies. Novel methods of detecting LM include detection of CSF circulating tumor cells and tumor cell-free DNA. A recent international guideline for a standardization of response assessment in LM may improve cross-trial comparisons as well as within-trial evaluation of treatment. An increasing number of retrospective studies suggest that molecular-targeted therapy, such as EGFR and ALK inhibitors in lung cancer, trastuzumab in HER2+ breast cancer, and BRAF inhibitors in melanoma, may be effective as part of the multidisciplinary management of LM. Prospective randomized trials with standardized response assessment are needed to further validate these preliminary findings.

"Countersinking" of reservoir in an irradiated patients can decrease tension on scalp closure

Background:

Subcutaneous reservoirs are used to provide therapy by establishing access to cerebrospinal fluid. However, it is associated with complications such as hemorrhage, infection, malfunction, and malpositioning. In an irradiated field with thin skin, use of reservoir can result in wound dehiscence, wound infection, and device extrusion.

Case Description:

We introduced a “countersinking” technique for the reservoir placement which involves the creation of bony recess in the skull to effectively accommodate the reservoir and decrease the protrusion. “Countersinking” of the reservoir can result in tension-free closure of the scalp and allow durable coverage of the reservoir. In the representative case, the incisional wound healed completely without any concern for wound dehiscence and the countersink technique may have contributed to effective healing of the radiated scalp.

Conclusion:

Countersinking of the reservoir can be a strategy to prevent complications such as wound dehiscence, and device extrusion in any patient, but in irradiated patients with very thin skin it also enables tension-free closure of the wound.

Ommaya reservoir-related infections: clinical manifestations and treatment outcomes

OBJECTIVES

As infection is a severe complication of Ommaya reservoirs (OR), and existing data is limited, herein we describe the largest study of the clinical manifestations and treatment outcomes of Ommaya reservoir-related infections (ORRI).

METHODS

We retrospectively reviewed the records of all patients at our institution who had an OR placed, and developed a definite device-related infection between 2001 and 2011.

RESULTS

Among 501 OR placements, 40 patients (8%) developed an ORRI. These presented with meningitis and/or meningoencephalitis (60%), cellulitis (20%), or a combination thereof (20%). Approximately 40% occurred ≤30 days of OR placement, while 60% occurred ≤10 days after the device was last accessed. Only 20% presented with leukocytosis, while another 18% had a normal cerebrospinal fluid (CSF). Gram-positive skin flora accounted >80% of the pathogens. The median hospital stay and duration of antibiotics were 13 and 24 days, respectively. Although mortality rates (≈10%) were similar among all treatment groups (p > 0.99), shorter hospitalization and antimicrobial treatment durations were obtained with early versus late device removal (p < 0.038).

CONCLUSIONS

As clinical symptoms can be non-specific and CSF parameters may be within normal limits, a high suspicion for infection is required. The shortest hospitalization and treatment course was achieved with early device removal.

Ommaya reservoir infections: a 16-year retrospective analysis

OBJECTIVES

Ommaya reservoirs (OmR) are used in the treatment of cancer yet risk factors and outcome of infection are not well characterized. We therefore examined our experience with this device.

METHODS

Using administrative databases, we identified all patients with OmR in situ between 1993 and 2008 at Memorial Sloan-Kettering Cancer Center. Charts were reviewed for laboratory, demographic, and clinical information.

RESULTS

During the study period, 616 patients with OmRs received care at MSKCC comprising 462,467 Ommaya-days. 34 patients with OmR infection were identified (5.5% of patients, 0.74 infections per 10,000 Ommaya-days). 32% of infections occurred within 30 days of OmR placement. Most (74%) OmR infections occurring after 30 days post-placement were associated with OmR access in the preceding 30 days. Recovered organisms included coagulase-negative staphylococci (56%) and Propionibacterium acnes (24%). 70% of patients had fever and/or headache and 69% had cerebrospinal fluid pleocytosis. 50% of patients had the reservoir removed during treatment of the infection.

CONCLUSIONS

OmR infection occurs in one of every 20 persons with the device. A third of the infections appear related to OmR placement while the remainder may occur at any time and usually are associated with recent reservoir access. Treatment often includes device removal.

Carcinomatous meningitis: Leptomeningeal metastases in solid tumors

Leptomeningeal metastasis (LM) results from metastatic spread of cancer to the leptomeninges, giving rise to central nervous system dysfunction. Breast cancer, lung cancer, and melanoma are the most frequent causes of LM among solid tumors in adults. An early diagnosis of LM, before fixed neurologic deficits are manifest, permits earlier and potentially more effective treatment, thus leading to a better quality of life in patients so affected. Apart from a clinical suspicion of LM, diagnosis is dependent upon demonstration of cancer in cerebrospinal fluid (CSF) or radiographic manifestations as revealed by neuraxis imaging. Potentially of use, though not commonly employed, today are use of biomarkers and protein profiling in the CSF. Symptomatic treatment is directed at pain including headache, nausea, and vomiting, whereas more specific LM-directed therapies include intra-CSF chemotherapy, systemic chemotherapy, and site-specific radiotherapy. A special emphasis in the review discusses novel agents including targeted therapies, that may be promising in the future management of LM. These new therapies include anti-epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors erlotinib and gefitinib in nonsmall cell lung cancer, anti-HER2 monoclonal antibody trastuzumab in breast cancer, anti-CTLA4 ipilimumab and anti-BRAF tyrosine kinase inhibitors such as vermurafenib in melanoma, and the antivascular endothelial growth factor monoclonal antibody bevacizumab are currently under investigation in patients with LM. Challenges of managing patients with LM are manifold and include determining the appropriate patients for treatment as well as the optimal route of administration of intra-CSF drug therapy.

Leptomeningeal metastases from solid malignancy: a review

Leptomeningeal metastases (LMM) consist of diffuse involvement of the leptomeninges by infiltrating cancer cells. In solid tumors, the most frequent primary sites are lung and breast cancers, two tumors where the incidence of LMM is apparently increasing. Careful neurological examination is required to demonstrate multifocal involvement of the central nervous system (CNS), cranial nerves, and spinal roots, which constitute the clinical hallmark of the disease. Cerebro-spinal fluid (CSF) analysis is almost always abnormal but only a positive cytology or demonstration of intrathecal synthesis of tumor markers is diagnostic. T1-weighted gadolinium-enhanced sequence of the entire neuraxis (brain and spine) plays an important role in supporting the diagnosis, demonstrating the involved sites and guiding treatment. Radionuclide CSF flow studies detect CSF compartmentalization and are useful for treatment planning. Standard therapy relies mainly on focal irradiation and intrathecal or systemic chemotherapy. Studies using other therapeutic approaches such as new biological or cytotoxic compounds are ongoing. The overall prognosis remains grim and quality of life should remain the priority when deciding which treatment option to apply. However, a sub-group of patients, tentatively defined here, may benefit from an aggressive treatment.

Late onset Ommaya reservoir infection due to Staphylococcus aureus: case report and review of Ommaya Infections

The Ommaya reservoir system has been used for the treatment of chronic central nervous system infections and intracranial tumors for more than three decades. The majority of reported Ommaya reservoir infections occur proximate to the time the device is accessed. A review of the literature reveals that late onset of reservoir infection is quite rare. We report a case of Ommaya reservoir infection due to Staphylococcus aureus that was diagnosed seven years after its insertion and usage for intracerebral non-Hodgkin's lymphoma and review the literature on the microbiology and management of Ommaya reservoir infections.

Toxicity of treatment for neoplastic meningitis

Neoplastic seeding of the leptomeninges often signifies limited life expectancy. Still, patients are frequently offered aggressive multimodality therapies to palliate symptoms, and, one hopes, to prolong survival. Treatment modalities directed at the central nervous system (CNS) include radiotherapy, intra-cerebrospinal fluid (CSF) chemotherapy, standard systemic chemotherapy, and systemic high-dose chemotherapy. Because many of these modalities are used in combination, it is often difficult to discern which mode is the predominant cause of either acute or delayed complications. This review summarizes the incidence, clinical manifestations, laboratory findings, and pathology related to acute and delayed toxicity of treatment. It describes complications associated with radiotherapy, the use of an intraventricular implanted device (ie, Ommaya device), adverse effects of intra-CSF chemotherapy, and neurotoxicity, either associated with high-dose chemotherapy or manifested as delayed and chronic complications of combined therapies. All CNS-directed therapies are associated with a high rate of complications. The adverse effects of therapy profoundly affect the patient's quality of life, both at the acute phase of treatment and in late and chronic complications after therapy is completed. Intra-CSF chemotherapy is associated with a high rate of acute, reversible adverse effects that sometimes evolve into life-threatening medical conditions. Devastating delayed complications, mainly described as leukoencephalopathy, develop in more than 50% of patients who survive for extended periods and often lead to progressive loss of cognitive capacities. Careful assessment of the benefits and potential adverse reactions to a particular therapy regimen is mandated.

Intraventricular concentration times time (C x T) methotrexate and cytarabine for patients with recurrent meningeal leukemia and lymphoma

BACKGROUND

Intraventricular chemotherapy results in more uniform drug distribution within the subarachnoid space and allows for more flexible drug administration schedules. The authors report their experience with an intraventricular concentration times time (C x T) chemotherapy regimen for recurrent meningeal leukemia and lymphoma.

METHODS

Twenty-one patients (median age, 11.6 years) received C x T therapy for meningeal acute lymphoblastic leukemia (n = 18), Burkitt's lymphoma (n = 2), or undifferentiated leukemia (n = 1). Prior therapy included standard intrathecal (IT) methotrexate and cytarabine, cranial or craniospinal radiation (median, 24 Gy), and 0-5 experimental treatment modalities. C x T induction therapy consisted of 2 mg of intraventricular methotrexate administered daily for 3 days every 10 days, for 4 courses. Patients were then consolidated with 4 courses of alternating intraventricular cytarabine (15 mg/day) or methotrexate (2 mg/day) daily for 3 days every 2 weeks (2 courses of methotrexate and 2 courses of cytarabine). Maintenance therapy consisted of alternating monthly courses of C x T methotrexate or cytarabine.

RESULTS

Ninety-three percent of patients (14 of 15) who were evaluable for response achieved a complete remission in a median of 10 days (range, 2-40 days). Median remission duration was 15 months. Fourteen patients died of recurrent disease or systemic treatment-related complications; 2 patients are alive, off treatment, and in continuous complete remission for 59+ and 89+ months; 1 patient experienced a meningeal relapse at 24 months on C x T therapy but was reinduced with the C x T regimen, received craniospinal radiation, and is in remission at 142+ months; and 3 are alive with disease at 32+, 72+, and 81+ months. One patient was lost to follow-up.

CONCLUSIONS

This regimen appears to be an effective and well-tolerated palliative treatment for patients with recurrent meningeal leukemia and lymphoma.

Hemiparkinsonism as a complication of an Ommaya reservoir. Case report

The authors describe the case of a 28-year-old woman who developed the following symptoms in her right hand: a lasting resting tremor, transient focal rigidity, and paresthesia. These deficits occurred following treatment with intrathecal methotrexate via an Ommaya reservoir which was placed too deeply, resulting in trauma to the contralateral mesencephalon.